New insurance guidelines would undermine rules of the Affordable Care Act

https://www.washingtonpost.com/national/health-science/new-insurance-guidelines-would-undermine-rules-of-the-affordable-care-act/2018/11/29/ff467f46-f357-11e8-aeea-b85fd44449f5_story.html?utm_term=.c279fcb895a6&wpisrc=al_news__alert-hse–alert-national&wpmk=1

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The Trump administration is urging states to tear down pillars of the Affordable Care Act, demolishing a basic rule that federal insurance subsidies can be used only for people buying health plans in marketplaces created under the law.

According to advice issued Thursday by federal health officials, states would be free to redefine the use of those subsidies, which began in 2014. They represent the first help the government ever has offered middle-class consumers to afford monthly premiums for private insurance.

States could allow the subsidies to be used for health plans the administration has been promoting outside the ACA marketplaces that are less expensive because they provide skimpier benefits and fewer consumer protections. In an even more dramatic change, states could let residents with employer-based coverage set up accounts in which they mingle the federal subsidies with health-care funds from their job or personal tax-deferred savings funds to use for premiums or other medical expenses.

If some states take up the administration’s offer, it would undermine the ACA’s central changes to the nation’s insurance system, including the establishment of nationwide standards for many kinds of health coverage sold in the United States.

Another goal of the ACA, the sprawling 2010 law that was President Barack Obama’s preeminent domestic accomplishment, was to concentrate help on the individual insurance market serving people who do not have access to affordable health benefits through a job. Prices were often out of control and discrimination against unhealthy people was more prevalent before the ACA imposed required benefits, prohibited insurers from charging more to people with preexisting conditions and created a federal health exchange and similar state-run marketplace in which private insurance companies compete for customers.

The ACA health plans have been the only ones for which consumers can use the subsidies, designed to help customers with incomes up to the middle class — 400 percent of the federal poverty line — afford the premiums.

The new advice, called “waiver concepts” because they are ideas for how states could get federal permission to deviate from the law’s basic rules, stray from both of those goals. And it would allow states to set different income limits for the subsidies — higher or lower than the federal one.

The day before they were released by Seema Verma, administrator of the Department of Health and Human Services’ Centers for Medicare and Medicaid Services, an analysis by the Brookings Institution questioned the legality of the content and method of these concepts. The analysis by Christen Linke Young, a Brookings fellow and HHS employee during the Obama administration, contends that “there are serious questions” about whether the changes are allowable under the law and that “at the very least, it is likely invalid” for CMS to issue the advice to states without going through the formal steps to change federal regulations.

In a statement Thursday, HHS Secretary Alex Azar said: “The Trump administration is committed to empowering states to think creatively about how to secure quality, affordable healthcare choices for their citizens.” He said the four recommendations issued Thursday, including new accounts in which consumers could pool federal subsidies and other funds, are intended to “show how state governments can work with HHS to create more choices and greater flexibility in their health insurance markets, helping to bring down costs and expand access to care.”

In a midday speech before a gathering of the conservative American Legislative Exchange Council, Verma delivered a broadside against the health-care law in explaining the rationale for freeing states to rework health policies on their own. “It was such a mistake to federalize so much of health care in the ACA,” said Verma, who worked as a consultant to states before becoming one of Trump’s senior health-care advisers. While the law sought to make health coverage more available and affordable, she said, “the insurance problem has not been solved. For many Americans it’s even been made worse.”

In urging states to consider the changes, CMS is renaming a provision of the law, known as 1332, which until now has mainly been used to give states permission to create programs to ease the burden on insurers of high-cost customers. CMS is switching the name to “State Relief and Empowerment Waivers,” emphasizing the administration’s desire to hand off health-care policies to states.

The changes go beyond a variety of other steps Trump administration health officials have taken in the past year to weaken the ACA, which the president has opposed vociferously.

Until now, they have focused on bending the ACA’s rules for health plans themselves. The administration has rewritten regulations to make it easier for Americans to buy two types of insurance that is relatively inexpensive because it does not contain all the benefits and consumer protections that the ACA typically requires.

The new steps go further by undercutting the basic ACA structure of the individual insurance marketplaces created for those who cannot get affordable health benefits through a job.

During a conference call with journalists, Verma said that no state would be allowed to retreat from a popular aspect of the ACA that protects people with preexisting medical conditions from higher prices or an inability to buy coverage.

She said that, in evaluating states’ proposals, CMS would focus on several considerations, including whether changes would foster comprehensive coverage and affordability and would not increase the federal deficit. She said federal officials would favor proposals that help, in particular, low-income residents and people with complex medical problems.

Verma reiterated an administration talking point that insurance rates have escalated since the ACA was passed and that health plan choices within ACA marketplaces have dwindled. However, the current ACA enrollment period, lasting until mid-December, is different from the previous few because prices for the most popular tier of coverage have stabilized in many places and more insurers are taking part in the marketplaces.

 

ACA Slow Enrollment as Uninsured Rate Remains Steady

https://www.healthaffairs.org/do/10.1377/hblog20181120.831184/full/

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In most states across the country, the open enrollment period for 2019 began on November 1 and will end on December 15, 2018. As we near the halfway point for enrollment—at least for the states with a federal marketplace—recent federal data suggests that enrollment in Affordable Care Act (ACA) marketplace plans is lagging relative to last year.

In its “week 2” enrollment snapshot, the Centers for Medicare and Medicaid Services (CMS) announced that nearly 1.2 million consumers selected a plan between November 1 and November 10 in the 39 states that use HealthCare.gov. Of these consumers, about 275,000 were new consumers while about 901,000 were renewing their coverage from last year. This reflects a significant increase from the first three days of open enrollment when about 371,000 consumers selected a plan.

“Week 2” plan selections are down by about 302,000 consumers relative to last year. This can be read as between an 8 to 13 percent decline in plan selections compared to last year, when a total of 11.8 million consumers in all 50 states and DC selected or were automatically reenrolled in a marketplace plan. Enrollment remained largely stable from 2017 to 2018 despite a shortened open enrollment period and significant cuts to advertising and navigator funding.

This year, however, brings additional changes that could be contributing to what is, at least so far, depressed enrollment through HealthCare.gov. These changes include repeal of the individual mandate penalty; 2019 is the first year that consumers will no longer pay a penalty for being uninsured under the ACA. In addition, new federal rules are enabling expanded access to non-ACA plans (such as short-term, limited-duration insurance and association health plans). These non-ACA plans typically have a much lower premium than ACA plans and could lure consumers away from the marketplace.

It is too early to tell if the reduced enrollment trend will hold and if this pattern will continue. Enrollment may increase significantly before the December 15 deadline, and millions of Americans will enroll in coverage before the end of the year.

The declines are, however, significant. The former chief marketing officer for HealthCare.gov recently noted that the data “should be a wake-up call to everyone who cares about people having health care … on the need to step up efforts to raise awareness.” CMS intends to release enrollment snapshots on a weekly basis. Each snapshot also includes point-in-time estimates of call center activity and visits to HealthCare.gov and CuidadoDeSalud.gov, among other data.

The new open enrollment data comes at a time when the uninsured rate continues to remain steady. Data from the National Center for Health Statistics—in reports both from late August and November—shows that the uninsured rate of about 8.8 percent for 2018 remains largely unchanged from 2017. Although there was not a significant shift from 2017 to 2018, there has been a sizable drop in the uninsured rate since the ACA was enacted in 2010. Between 2010 and the first six months of 2018, the uninsured rate dropped from 16 percent (48.6 million people) to 8.8 percent (28.5 million people).

 

 

Can a Divided Congress Fix Health Care?

https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-november-2018-priorities-congress-future-aca-medicaid-expansion/

The Kaiser Family Foundation’s latest tracking poll finds that costs and affordability are the health care issues Americans most want Congress to address — though the public remains highly skeptical that Democrats and Republicans can actually work together to do anything on health care.

The poll also finds that the favorability of the Affordable Care Act has risen to 53 percent and that 59 percent of people living in states that have not expanded Medicaid under the ACA want such an expansion.

Key Findings:

  • The November KFF Health Tracking Poll, conducted the week after the 2018 midterm election, finds a majority of the public wants the new Democratic majority in the U.S. House of Representatives to work with Republicans on legislation to address the major problems facing the country as well as conduct oversight of the Trump administration’s actions on policies such as health care. Yet, few Americans are “very confident” (6 percent) that Republicans and Democrats in Congress will be able to work on bipartisan legislation to address the health care issues facing the country.
  • The midterm elections brought Medicaid expansion to three additional states, bringing the total number of states that have expanded their Medicaid programs to cover more low-income uninsured adults to 37 (including Washington, D.C.). Those living in states that have not expanded their Medicaid programs continue to hold a favorable view of Medicaid expansion and most would like to see their state expand their Medicaid program. And as a possible indicator of how some other states may expand their Medicaid programs in the future, most of those living in a non-expansion state say that if their state government chooses not to expand, voters themselves should be able to decide if their state expands their Medicaid program.
  • The new Democratic majority in the House all but guarantees the Affordable Care Act (ACA) will remain the law of the land for at least the next two years. The most recent tracking poll finds a slight uptick – largely driven by Democrats – in the overall favorability of the law (53 percent) and many of the ACA’s provisions continue to be quite popular with a majority of the public. But the poll also finds the public is largely unaware about the law’s sixth open enrollment period, and four in ten 18-64 year olds who buy their own insurance or are currently uninsured say they will choose to go without coverage in 2019.

    Most Americans say it is “very important” to keep the ACA provisions barring insurers from denying coverage or charging more (62%) to people with pre-existing conditions, even after hearing that these may have increased costs for some healthy people

  • A divided Congress does not mean that the coming year will not see any changes to the country’s health care system. There is an impending lawsuit, Texas v. United States, which may end the ACA’s protections for people with pre-existing medical conditions as well as the Trump administration’s recent actions allowing employers to be exempt from covering the full cost of birth control for their employees if they oppose to it due to religious or moral reasons, which could lead to substantial changes to health coverage for many Americans. This month’s tracking poll examines the public’s support for these proposed changes and examines the malleability of these opinions.

The Public’s Priorities for Next Congress

With Democratic gains in the U.S. House of Representatives during the 2018 midterm election, Democrats and Republicans will split control of Congress next year. These results will mean that President Trump will have a divided Congress for the first time in his presidency. About half of the public (53 percent) say oversight of the Trump administration’s actions on policies such as health care, education, and the environment should be a “top priority” for House Democrats in the coming year. This is similar to the share (55 percent) who say that working to enact new laws to address the major problems facing the country should be a “top priority” for House Democrats in the coming year and substantially larger than the share who say investigating corruption within President Trump’s administration should be a “top priority” (36 percent).

Majority of The Public Say Working To Enact New Legislation And Oversight Are Top Priorities For Democrats

Figure 1: Majority of The Public Say Working To Enact New Legislation And Oversight Are Top Priorities For Democrats

Unsurprisingly, the share of partisans who say each of these should be a “top priority” for Democrats in the U.S. House of Representatives varies drastically; majorities of Democrats saying conducting oversight (77 percent), working to enact legislation (67 percent), and investigating corruption (58 percent) should all be top priorities for the coming year. A majority of independents (54 percent) say working to enact legislation should be a “top priority,” while less than half of Republicans say any of these – including working to enact legislation – should be “a top priority” for House Democrats.

Figure 2: Most Democrats Say New Legislation, Oversight, and Investigating Corruption Are Top Priorities For House Democrats

Figure 2: Most Democrats Say New Legislation, Oversight, and Investigating Corruption Are Top Priorities For House Democrats

Immigration and Health Care Top Public’s Priorities

Similar to the issues driving voters in the 2018 midterm elections, the most recent KFF Health Tracking Poll finds immigration and health care as the top issues the public want to see the next Congress act on in 2019 with the issues offered largely driven by party identification. Overall, about one-fifth of voters offer immigration or border security (21 percent) when asked to say in their own words the issue Congress should work on next year. This is similar to the share of the public who offer health care (20 percent) as the top issue they want to see the next Congress work on. Fewer offer gun control/legislation (8 percent), tax reform (4 percent), or education (4 percent) as the issues they want to see Congress act on in 2019.

Four times as many Republicans (41 percent) offer immigration/border security as the issue they would most like the next Congress to act on in 2019 as Democrats (10 percent). On the other hand, health care is the top issue for Democrats. One-fourth of Democrats (27 percent) say health care is the issue they would most like to see the next Congress act on, compared to 11 percent of Republicans who say the same. Independents are divided across the top two issues, with similar shares offering immigration/border security (22 percent) and health care (21 percent) as the issues they want to see Congress work on.

Table 1: Immigration and Health Care Top Public’s Priorities for Next Congress
Thinking about next year, which issue would you most like the next Congress to act on in 2019? (open-end) Total Democrats Independents Republicans
Immigration/Border security 21% 10% 22% 41%
Health care 20 27 21 11
Gun control/legislation 8 13 4 8
Tax reform 4 2 7 8
Education 4 7 2
Note: Only top five responses shown. Question asked of half sample.
COST AND AFFORDABILITY CONTINUES TO DOMINATE HEALTH CARE PRIORITIES

When asked which health care issue they would most like to see the next Congress act on in 2019, more Americans offer issues around health care affordability and cost (19 percent) than other health care issues including the 2010 Affordable Care Act (ACA) (10 percent) or Medicare (6 percent). Health care affordability and cost are also the most frequently mentioned health care issues by Democrats (14 percent), independents (25 percent), and Republicans (17 percent). The ACA is the second most frequently mentioned health care issue among partisans, with Democrats saying they want to see Congress “protecting or improving the ACA” while Republicans say they want to see the next Congress “repealing the ACA.” Independents are divided on this issue, with similar shares saying they want to see Congress repealing and protecting the 2010 health care law.

Figure 3: Cost And Affordability Top Public’s Health Care Priorities For Next Congress

Figure 3: Cost And Affordability Top Public’s Health Care Priorities For Next Congress

While there appears to be consensus among the public on what health care issue they want to see Congress work on next year, not quite one-third are confident that Democrats and Republicans in Congress will be able to work together on bipartisan legislation to address the health care issues facing the country. In fact, seven in ten say they are either “not very confident” (34 percent) or “not at all confident” (35 percent) that Congress will be able to work on such bipartisan legislation, while fewer are confident, either “very confident” (six percent) or “somewhat confident” (24 percent), in Congress being able to work together.

Figure 4: Less Than One-Third Are Confident Congress Can Work Together To Address Health Care Issues Facing The Country

Figure 4: Less Than One-Third Are Confident Congress Can Work Together To Address Health Care Issues Facing The Country

Democrats are slightly more confident in the ability of Democrats and Republicans in Congress to be able to work together on bipartisan health care legislation (41 percent) compared to independents (27 percent) and Republicans (19 percent); yet, a majority across party identification say they are either “not very confident” or “not at all confident” (58 percent, 72 percent, and 79 percent, respectively).

The Future of the Affordable Care Act and Medicaid Expansion

The 2018 midterm elections have major implications for both the future of the 2010 health care law known as the Affordable Care Act (ACA) as well as one of its most popular provisions – individual state’s expansion of the Medicaid program for low-income people.

The Affordable Care Act

With Democrats regaining a majority in the U.S. House of Representatives for the first time since 2010, and without continued efforts among Republicans to repeal the ACA, the latest KFF Tracking Poll finds a slight uptick in the public’s view of the law with 53 percent saying they view law favorably compared to four in ten who have an unfavorable view of the law. This slight shift is largely driven by Democrats with about eight in ten saying they have a favorable opinion of the law, including about half (48 percent) who have a “very favorable” view. Similarly, three-fourths of Republicans (76 percent) continue to view the law unfavorably with more than half (54 percent) saying they have a “very unfavorable” opinion of the law.

Figure 5: Post-Election Tracking Poll Finds Slight Uptick in ACA Favorability, Largely Driven By Democrats

Figure 5: Post-Election Tracking Poll Finds Slight Uptick in ACA Favorability, Largely Driven By Democrats

AMERICANS CONTINUE TO HOLD FAVORABLE OPINIONS OF ACA PROVISIONS

Similar to previous KFF Tracking Polls, many of the ACA’s provisions continue to be quite popular, even across party lines. A majority of the public – regardless of party identification – hold favorable views of all of the ACA’s provisions with one exception (fewer than half of Republicans say they have a favorable opinion of the Medicare payroll tax increases on earnings for upper-income Americans).

Table 2: Americans’ Opinions of ACA Provisions
Percent who say they have a FAVORABLE opinion of each of the following provisions of the law: Total Democrats Independents Republicans
Allows young adults to stay on their parents’ insurance plans until age 26 82% 90% 82% 66%
Creates health insurance exchanges where small businesses and people can shop for insurance and compare prices and benefits 82 91 78 71
Provides financial help to low- and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage 81 92 82 63
Gradually closes the Medicare prescription drug “doughnut hole” so people on Medicare will no longer be required to pay the full cost of their medications 81 85 82 80
Eliminates out-of-pocket costs for many preventive services 79 88 78 68
Gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults 77 91 77 55
Requires employers with 50 or more employees to pay a fine if they don’t offer health insurance 69 88 61 56
Prohibits insurance companies from denying coverage because of a person’s medical history 65 70 66 58
Increases the Medicare payroll tax on earnings for upper-income Americans 65 77 69 42
Note. Some items asked of half samples.

In previous KFF Health Tracking Polls, one of the ACA’s provisions – the individual mandate which required nearly all Americans have health insurance or pay a fine – was consistently viewed unfavorably by a majority of the public. As part of the federal tax bill passed in 2017, Congress zeroed out the dollar amount and percentage of income penalties imposed by the individual mandate. Overall, three in ten Americans (31 percent) are aware that Congress has gotten rid of the penalty for not having health insurance, while four in ten (38 percent) incorrectly say Congress has not gotten rid of this penalty and an additional three in ten (31 percent) are unsure. The results are similar among those under 65 years old who either buy their own insurance or are currently uninsured with three in ten (31 percent) aware Congress has gotten rid of the penalty for not having health insurance.

Figure 6: Most Americans Are Not Aware Congress Has Gotten Rid Of The Penalty For Not Having Health Insurance

Figure 6: Most Americans Are Not Aware Congress Has Gotten Rid Of The Penalty For Not Having Health Insurance

Medicaid Expansion

Three states (Idaho, Nebraska, and Utah) voted during the 2018 election to expand their Medicaid program to cover more low-income residents, bringing the total number of states that have expanded their Medicaid programs to 37 states including Washington, D.C. Overall, about three-fourths of the public – including 77 percent of those living in non-expansion states – have a favorable view of the ACA’s provision that gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults. In addition, a majority (59 percent) of those living in non-expansion states would like to see their state expand Medicaid to cover more low-income uninsured people while one-third (34 percent) say they want to see their state keep Medicaid as it is today. A majority of Democrats and Democratic-leaning independents say they want to see their state expand Medicaid (84 percent) while most Republicans and Republican-leaning independents want to see their state keep Medicaid as it is today (65 percent).

Figure 7: Majority Of Residents In Non-Expansion States Want Their State To Expand Their Medicaid Programs

Figure 7: Majority Of Residents In Non-Expansion States Want Their State To Expand Their Medicaid Programs

Among those living in states without Medicaid expansion who want to see their state expand their Medicaid program, nearly nine in ten (51 percent of all residents living in non-expansion states) say that if their governor and state government choose not to expand Medicaid, voters themselves should be able to decide if their state expands Medicaid.

The ACA’s 2019 Open Enrollment Period

The ACA’s sixth open enrollment period for individuals who purchase health plans on their own began on November 2, 2018 and closes in most states on December 15, 2018.1 According to the Centers for Medicare and Medicaid Services, as of November 21, 2018, 1.9 million people have signed up for insurance through the federal marketplace, which is slightly less than in previous years.2

The most recent KFF Tracking Poll finds a majority of the group most directly affected by open enrollment (those 18-64 years old who either purchase their own insurance or are currently uninsured) are unaware of the current open enrollment deadlines. About one-fourth (24 percent) of this group is aware of the current deadline to buy insurance for 2019 while six in ten (61 percent) say they “do not know” the deadline and 16 percent either offer the wrong date, incorrectly say there is no deadline or that the deadline has passed, or refuse to answer the question.

Figure 8: About One-Fourth Of Those Who Buy Their Own Insurance Or Are Uninsured Know Current Open Enrollment Deadline

Figure 8: About One-Fourth Of Those Who Buy Their Own Insurance Or Are Uninsured Know Current Open Enrollment Deadline

Slightly less than half (45 percent) of those 18-64 who either purchase their own insurance or are currently uninsured, say they have heard or seen any ads in the past thirty days from an insurance company attempting to sell health insurance. Fewer – about three in ten (31 percent) say they have heard or seen any information about how to get health insurance under the health care law.

IT IS STILL UNCLEAR HOW TWO MAJOR CHANGES TO ACA MARKETPLACES WILL AFFECT OPEN ENROLLMENT

This year’s open enrollment period has two major changes brought about by Republicans and President Trump’s administration: the removal of the penalty for not having health insurance and the introduction of short-term health insurance plans. About half of 18-64 year olds who buy their own insurance or are currently uninsured say they plan to buy their own insurance in 2019, despite the elimination of the fine for people who don’t have health insurance, while four in ten (42 percent) say they will choose to go without coverage in 2019.

Figure 9: Unclear How Changes To Individual Mandate Penalty And New Short-Term Plans May Affect Open Enrollment

Figure 9: Unclear How Changes To Individual Mandate Penalty And New Short-Term Plans May Affect Open Enrollment

One option available to those who buy their own insurance that would not have satisfied the ACA individual mandate in previous years are short-term health insurance plans. These plans cost significantly less than ACA-compliant plans but provide fewer benefits and may not pay for care for some pre-existing medical conditions.3 About one-fifth (21 percent) of those under the age of 65 who buy their own insurance or are currently uninsured say that if they had the opportunity, they would want to purchase a short-term plan. Seven in ten say they would either continue going without coverage or keep the plan they have now.

Public Support Trump Administration’s Actions on Prescription Drug Advertisements, Divided on Actions Aimed at Women’s Health and Pre-Existing Coverage

In recent months, the Trump administration has announced several actions aimed at different aspects of the U.S. health care system. The most recent KFF Tracking Poll finds the public supports the Trump administration’s proposed actions on prescription drug advertisements, even after hearing counter-arguments. The public is more divided on the administration’s actions on women’s health and protections for people with pre-existing conditions.

PRESCRIPTION DRUG ADVERTISEMENTS

Earlier this year, President Trump announced a series of ideas aimed at lowering the price of prescription drugs. One of its key elements is to require drug manufacturers to publish list prices for their prescription drugs in television advertisements. About three-fourths (77 percent) favor the federal government requiring prescription drug advertisements to include a statement about how much the drug costs. In a rare instance of bipartisanship, this policy proposal is supported by a majority of Democrats (80 percent), independents (74 percent) and Republicans (77 percent).

Figure 10: Large Shares, Regardless Of Party, Favor Requiring Prescription Drug Advertisements To Include Pricing Information

Figure 10: Large Shares, Regardless Of Party, Favor Requiring Prescription Drug Advertisements To Include Pricing Information

After President Trump announced this proposal, there was some debate about how this could be implemented with opponents saying that since people often pay different prices for the same drug based on the type of insurance they have, including a price in a drug advertisement could be confusing to consumers. About one-fifth of those who originally supported this proposal change their minds after hearing this counter-argument, leaving a slight majority of the public (53 percent) continuing to support this proposal. On the other side of the debate, nearly half of those (7 percent of total) who originally opposed this proposal change their minds after hearing that putting the price of a drug in an advertisement would put pressure on drug companies to lower their prices.

Figure 11: Majority Of The Public Continue To Favor Putting Prices In Drug Advertisements Even After Hearing Counter-Arguments

Figure 11: Majority Of The Public Continue To Favor Putting Prices In Drug Advertisements Even After Hearing Counter-Arguments

EMPLOYER EXEMPTION FROM COVERING BIRTH CONTROL

On November 15, 2018, the Trump Administration issued final regulations expanding the types of employers that may be exempt from the Affordable Care Act’s (ACA) contraceptive coverage requirement to all nonprofit and closely-held for-profit employers with objections to contraceptive coverage based on religious beliefs or moral convictions, including private institutions of higher education that issue student health plans.4 Overall, six in ten (57 percent) of the public, including most women, oppose allowing employers to be exempt from the requirement to cover the full cost of prescription birth control in their plans if they object to it for religious or moral reasons.

Figure 12: Majorities Across Groups – Except For Republicans – Oppose Allowing Employers To Be Exempt From Covering Birth Control

Figure 12: Majorities Across Groups – Except For Republicans – Oppose Allowing Employers To Be Exempt From Covering Birth Control

Few individuals, on either side of the debate, change their minds about employers being exempt from covering the cost of prescription birth control for religious or moral reasons after hearing counter-arguments. About one-fourth (9 percent of total) change their minds and now oppose employer exemptions after hearing that this means some women would not be able to afford birth control. On the other side of the argument, one in eight (7 percent of total) now favor this exemption if they heard that some business owners feel like they are being forced to pay for a benefit that violates their religious or moral beliefs.

Figure 13: Few, On Either Side Of Debate, Change Minds About Employer Birth Control Coverage After Hearing Counter-Arguments

Figure 13: Few, On Either Side Of Debate, Change Minds About Employer Birth Control Coverage After Hearing Counter-Arguments

PROTECTIONS FOR PEOPLE WITH PRE-EXISTING MEDICAL CONDITIONS

In June 2018, President Trump’s administration announced – as part of a lawsuit known as Texas v. United States, brought by 20 Republican state attorneys general – it will no longer defend the ACA’s protections for people with pre-existing medical conditions. These provisions prohibit insurance companies from denying coverage based on a person’s medical history (known as guaranteed issue), and prohibit insurance companies from charging those with pre-existing conditions more for coverage (known as community rating). The impending suit, Texas v. United States, will decide, among other things, whether both of these protections are unconstitutional and if they will be deemed invalid beginning on January 1, 2019.

The majority of the public say it is “very important” to them that the ACA’s provisions protecting those with pre-existing conditions remain law even after hearing that these protections may have led to increased insurance costs for some healthy people. Sixty-five percent of the public say it is “very important” to them that the provision that prohibits health insurance companies from denying coverage because of a person’s medical history remains law. An additional fifth (22 percent) say it is “somewhat important” this provision remains law. Similarly, about six in ten say it is “very important” that the provision that prohibits health insurance companies from charging sick people more remains law, while an additional one in five (22 percent) say it is “somewhat important.”

Figure 14: Majorities Say Pre-Existing Condition Protections Are Very Important To Them

Figure 14: Majorities Say Pre-Existing Condition Protections Are Very Important To Them

If the judge ruling on Texas v. United States decides the ACA’s protections for people with pre-existing conditions are unconstitutional, a majority of the public – including 87 percent of Democrats, 67 percent of independents, and about half of Republicans – say they would want their state to establish protections for people with pre-existing health conditions, even if this means some healthy people may pay more for coverage.

Figure 15: Majorities Say They Would Support State Action If ACA’s Pre-Existing Condition Protections Are Ruled Unconstitutional

Figure 15: Majorities Say They Would Support State Action If ACA’s Pre-Existing Condition Protections Are Ruled Unconstitutional

 

 

With Divided Congress, Health Care Action Hightails It to the States

https://www.rollcall.com/news/policy/divided-congress-health-care-action-states

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Medicaid expansion was the biggest winner in last week’s elections.

Newly-elected leaders in the states will be in a stronger position than those in Washington to steer significant shifts in health care policy over the next couple of years as a divided Congress struggles with gridlock.

State Medicaid work requirements, prescription drug prices, insurance exchanges and short-term health plans are among the areas with the potential for substantial change. Some states with new Democratic leaders may also withdraw from a multistate lawsuit aimed at killing the 2010 health care law or look for ways to curb Trump administration policies.

But last week’s biggest health care winner is undeniably Medicaid expansion, with upwards of half a million low-income Americans poised to gain insurance coverage following successful expansion ballot initiatives and Democratic victories in key governors’ races.

“In state health policy, it was a big election,” said Trish Riley, executive director of the nonpartisan National Academy for State Health Policy. “It was a year when many candidates had pretty thoughtful and comprehensive proposals.”

Boost for Medicaid expansion

Voters in three deep-red states — Nebraska, Idaho and Utah — bucked their Republican lawmakers by approving ballot initiatives to extend Medicaid coverage to more than 300,000 people.

Meanwhile, Democratic gubernatorial wins in Kansas and Wisconsin boosted the chances of expansion in those states. And Maine’s new governor-elect is expected to act quickly to grow the government insurance program when she takes office in January.

The election outcomes could bring the biggest increase in enrollment since an initial burst of more than two dozen states expanded Medicaid under the 2010 health care law in the early years of the landmark law’s rollout.

“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong,” said Jonathan Schleifer, head of The Fairness Project, an advocacy group that supported the initiatives, referring to the 2010 health care law. “Americans want to live in a country where everyone can go to the doctor without going bankrupt.”

The successful ballot initiatives require state leaders to move quickly toward expansion. In Idaho, the state must submit an expansion plan to federal officials within 90 days of the new law’s approval, while Nebraska must submit its plan by April 1, according to the nonpartisan Kaiser Family Foundation. Utah’s new law also calls for the state to expand beginning April 1.

In Kansas, where Medicaid supporter Laura Kelly prevailed, state lawmakers passed expansion legislation last year only to have it vetoed by the governor. Meanwhile, Wisconsin’s new Democratic governor Tony Evers, who eked out a win over Republican incumbent Scott Walker, has said he will “take immediate action” to expand, though he faces opposition from a Republican-controlled legislature.

Expansions in the five states would bring the number of states that adopted expansion under the health law to 38, plus the District of Columbia.

Still, Democrats fell short of taking one of the biggest Medicaid expansion prizes — Florida — after Andrew Gillum’s defeat. The outcome of Georgia’s tight governor’s race was still unclear as of Monday, with Republican Brian Kemp holding a narrow lead over Democrat Stacey Abrams. Both Abrams and Gillum made health care, and Medicaid expansion in particular, central to their campaigns.

Florida might be a 2020 target for an expansion ballot initiative, along with other states such as Missouri and Oklahoma, according to The Fairness Project.

Expansion supporters also suffered defeat last week in Montana, where voters did not approve a ballot initiative that would have extended the state’s existing Medicaid expansion, which covers nearly 100,000 people but is slated to expire next year. However, state lawmakers have until June 30 to reauthorize the program, according to Kaiser.

In Maine, Democratic gubernatorial winner Janet Mills is expected to expedite expansion implementation. GOP Gov. Paul LePage stymied implementation over the past year, despite nearly 60 percent of voters approving an expansion ballot initiative in 2017.

Medicaid’s future

The midterm results carry other ramifications for Medicaid, including whether states embrace or move away from controversial work requirements backed by the Trump administration.

Gretchen Whitmer, a Democrat who won Michigan’s governor race, opposed the idea and could shift away from an existing plan to institute them that’s awaiting federal approval.

“This so-called work requirement is not for one second about getting people back to work. If it was, it would have been focused on leveling barriers to employment like opening up training for skills or giving people child care options or transportation options,” Whitmer said in a September interview with Michigan Radio. “It was about taking health care away from people.”

Kansas, Wisconsin and Maine also have work requirement proposals that new Democratic governors could reverse.

But experts also say it’s possible some states, including those with Democratic governors, could end up pursuing Medicaid work requirements if that’s what it takes to get conservative legislators to accept expansion like Virginia did earlier this year.

Nebraska Republican state senator John McCollister, who supports expansion, predicted recently that the legislature would fund the voter-approved expansion initiative. But he indicated lawmakers might pursue Medicaid work requirements too.

Marie Fishpaw, director of domestic policy studies at the conservative Heritage Foundation, warned that states expanding Medicaid would face challenges. She called expansion “a poor instrument for achieving the goal that they’re trying to achieve.”

A number of new governors, including Whitmer, could pursue the so-called “Medicaid buy-in” concept.

More than a dozen state legislatures, such as in Minnesota and Iowa, explored the idea in recent years, according to State Health and Value Strategies, part of the nonprofit Robert Wood Johnson Foundation. Nevada lawmakers passed a “Medicaid buy-in” plan last year that was vetoed by the governor.

There are a variety of ways to implement such a program, but the goal is to expand health care access by leveraging the government insurance program, such as by creating a state-sponsored public health plan option on the insurance exchanges that consumers could buy that relies on Medicaid provider networks. Illinois, New Mexico, Maine and Connecticut are among the states that could pursue buy-in programs, Riley said. States are considering the concept as a way to increase affordability and lower cost growth by getting more mileage out of the lower provider rates Medicaid pays, said Katherine Hempstead, a senior policy adviser with Robert Wood Johnson Foundation.

“So many [people] struggle with the affordability of health care,” Hempstead said. “That is an environment in which Medicaid buy-in opportunities could flourish.”

Health care law

This month’s election also carries implications for the future of states’ administration of the 2010 health care law.

States that flipped to Democratic governors could switch to creating their own insurance exchanges rather than relying on the federal marketplace, said Joel Ario, a health care consultant with Manatt Phelps & Phillips and the former head of the federal health insurance exchange office under the Obama administration. The costs of running an exchange have come down in recent years, so it’s potentially cheaper for a state to run its own, Ario said.

Trump administration actions, such as cuts in federal funding for insurance navigators that help consumers enroll and the expansion of health plans that don’t comply with the law, may make states such as Michigan or Wisconsin rethink use of the federal exchange, he said.

“If [the administration] continues to promote policies that really leave a bad taste in the mouth for Democratic governors, I think they’ll be asking questions,” Ario said.

States where governors and attorneys general offices went from red to blue are likely to pull out of a lawsuit by 20 state officials that aims to take down the health care law, he added.

Wisconsin’s Evers vowed that his first act in office will be to withdraw from the lawsuit.

“I know that the approximately 2.4 million Wisconsinites with a pre-existing condition share my deep concern that this litigation jeopardizes their access to quality and affordable health care,” Evers wrote in a letter he said he plans to send to the state attorney general.

Hempstead said that states with both Republican and Democratic leaders will likely continue to pursue reinsurance programs, which cover high-cost patients, to bolster their marketplaces.

Republican governors could also pursue waivers under a recent Trump administration guidance that allows states to circumvent some requirements of the health law under exemptions known as 1332 waivers. But experts say it’s too soon to know exactly what approaches states might take.

“It will be interesting to see what the 1332 guidance means and whether it opens doors for some things and not for others,” Hempstead said. States that shifted to Democratic governors could also look to ban some Trump-supported policies, such as expansions of short-term and association health plans that avoid the health care law’s rules.

States are also likely to take steps to address high prescription drug costs in the coming years, with a number of new governors wanting to improve transparency, explore drug importation from other countries and target price gouging, Riley said.

“There’s a long history of the states testing, fixing, tweaking and informing the national debate,” said Riley.

 

FTC: Florida company made $100M selling fake insurance

https://www.beckershospitalreview.com/legal-regulatory-issues/ftc-florida-company-made-100m-selling-fake-insurance.html

Image result for skinny health plans

A federal judge has temporarily shut down Miami-based Simple Health Plans at the request of the Federal Trade Commission.

In a federal complaint against Simple Health Plans, the company’s owner and five other entities, the FTC alleges Simple Health Plans collected more than $100 million by selling worthless health plans to thousands of people. The company allegedly misled consumers to think they were buying comprehensive “PPO” health insurance plans when they were actually purchasing plans that provided no coverage for pre-existing conditions or prescription medications.

Many of the people who purchased plans from Simple Health Plans are facing hefty medical bills for expenses they assumed would be covered by their health insurance plan. In addition, because the limited health plans do not qualify as health insurance under the ACA, some people were subject to a fee imposed on those who can afford to buy health insurance but choose not to.

The FTC is seeking to permanently shut down Simple Health Plans and to have the company return money to consumers.

 

 

Pre-existing conditions: Does any GOP proposal match the ACA?

https://www.politifact.com/truth-o-meter/article/2018/oct/17/pre-existing-conditions-does-any-gop-proposal-matc/?fbclid=IwAR2QXSwiwRryxaHWJVgO3evTUtJPk6QcV1HkxkaI2qq3iPWqsrXqGA0qPeY

From a routine visit to a critical exam, the stethoscope remains one of the most common physician tools. (Alex Proimos, via Flickr Creative Commons)

In race after race, Democrats have been pummeling Republicans on the most popular piece of Obamacare, protections for pre-existing conditions. No matter how sick someone might be, today’s law says insurance companies must cover them.

Republican efforts to repeal and replace Obamacare have all aimed to retain the guarantee that past health would be no bar to new coverage.

Democrats aren’t buying it.

In campaign ads in NevadaIndianaFloridaNorth Dakota, and more, Democrats charged their opponents with either nixing guaranteed coverage outright or putting those with pre-existing conditions at risk. The claims might exaggerate, but they all have had a dose of truth.

Republican proposals are not as air tight as Obamacare.

We’ll walk you through why.

The current guarantee

In the old days, insurance companies had ways to avoid selling policies to people who were likely to cost more than insurers wanted to spend. They might deny them coverage outright, or exclude coverage for a known condition, or charge so much that insurance became unaffordable.

The Affordable Care Act boxes out the old insurance practices with a package of legal moves. First, it says point-blank that carriers “may not impose any preexisting condition exclusion.” It backs that up with another section that says they “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

Those two provisions apply to all plans. The third –– community rating –– targets insurance sold to individuals and small groups (about 7 percent of the total) and limits the factors that go into setting prices. In particular, while insurers can charge older people more, they can’t charge them more than three times what they charge a 21-year-old policy holder.

Wrapped around all that is a fourth measure that lists the essential health benefits that every plan, except grandfathered ones, must offer. A trip to the emergency room, surgery, maternity care and more all fall under this provision. This prevents insurers from discouraging people who might need expensive services by crafting plans that don’t offer them.

At rally after rally for Republicans, President Donald Trump has been telling voters “pre-existing conditions will always be taken care of by us.” At an event in Mississippi, he faulted Democrats, saying, they have no plan,” which ignores that Democrats already voted for the Obamacare guarantees.

At different times last year, Trump voiced support for Republican bills to replace Obamacare. The White House said the House’s American Health Care Act “protects the most vulnerable Americans, including those with pre-existing conditions.” A fact sheet cited $120 billion for states to keep plans affordable, along with other facets in the bill.

But the protections in the GOP plans are not as strong as Obamacare. One independent analysis found that the bill left over 6 million people exposed to much higher premiums for at least one year. We’ll get to the congressional action next, but as things stand, the latest official move by the administration has been to agree that the guarantees in the Affordable Care Act should go. It said that in a Texas lawsuit tied to the individual mandate.

The individual mandate is the evil twin of guaranteed coverage. If companies were forced to cover everyone, the government would force everyone (with some exceptions) to have insurance, in order to balance out the sick with the healthy. In the 2017 tax cut law, Congress zeroed out the penalty for not having coverage. A few months later, a group of 20 states looked at that change and sued to overturn the entire law.

In particular, they argued that with a toothless mandate, the judge should terminate protections for pre-existing conditions.

The U.S. Justice Department agreed, writing in its filing “the individual mandate is not severable from the ACA’s guaranteed-issue and community-rating requirements.”

So, if the mandate goes, so does guaranteed-issue.

The judge has yet to rule.

Latest Republican plan has holes

In August, a group of 10 Republican senators introduced a bill with a title designed to neutralize criticism that Republicans don’t care about this issue. It’s called Ensuring Coverage for Patients with Pre-Existing Conditions. (A House Republican later introduced a similar bill.)

The legislation borrows words directly from the Affordable Care Act, saying insurers “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

But there’s an out.

The bill adds an option for companies to deny certain coverage if “it will not have the capacity to deliver services adequately.”

To Allison Hoffman, a law professor at the University of Pennsylvania, that’s a big loophole.

“Insurers could exclude someone’s preexisting conditions from coverage, even if they offered her a policy,” Hoffman said. “That fact alone sinks any claims that this law offers pre-existing condition protection.”

The limit here is that insurers must apply such a rule across the board to every employer and individual plan. They couldn’t cherry pick.

But the bill also gives companies broad leeway in setting premiums. While they can’t set rates based on health status, there’s no limit on how much premiums could vary based on other factors.

The Affordable Care Act had an outside limit of 3 to 1 based on age. That’s not in this bill. And Hoffman told us the flexibility doesn’t stop there.

“They could charge people in less healthy communities or occupations way more than others,” Hoffman said. “Just guaranteeing that everyone can get a policy has no meaning if the premiums are unaffordable for people more likely to need medical care.”

Rodney Whitlock, a health policy expert who worked for Republicans in Congress, told us those criticisms are valid.

“Insurers will use the rules available to them to take in more in premiums than they pay out in claims,” Whitlock said. “If you see a loophole and think insurers will use it, that’s probably true.”

Past Republican plans also had holes

Whitlock said more broadly that Republicans have struggled at every point to say they are providing the same level of protection as in the Affordable Care Act.

“And they are not,” Whitlock said. “It is 100 percent true that Republicans are not meeting the Affordable Care Act standard. And they are not trying to.”

The House American Health Care Act and the Senate Better Care Reconciliation Act allowed premiums to vary five fold, compared to the three fold limit in the Affordable Care Act. Both bills, and then later the Graham-Cassidy bill, included waivers or block grants that offered states wide latitude over rates.

Graham-Cassidy also gave states leeway to redefine the core benefits that every plan had to provide. Health law professor Wendy Netter Epstein at DePaul University said that could play out badly.

“It means that insurers could sell very bare-bones plans with low premiums that will be attractive to healthy people, and then the plans that provide the coverage that sicker people need will become very expensive,” Epstein said.

Insurance is always about sharing risk. Whether through premiums or taxes, healthy people cover the costs of taking care of sick people. Right now, Whitlock said, the political process is doing a poor job of resolving how that applies to the people most likely to need care.

“The Affordable Care Act set up a system where people without pre-existing conditions pay more to protect people who have them,” Whitlock said. “Somewhere between the Affordable Care Act standard and no protections at all is a legitimate debate about the right tradeoff. We are not engaged in that debate.”

 

 

The ACA Protects People with Preexisting Conditions; Proposed Replacements Would Not

https://www.commonwealthfund.org/blog/2018/aca-protects-people-preexisting-conditions-proposed-replacements-would-not?omnicid=EALERT%%jobid%%&mid=%%emailaddr%%

Patient with preexisting condition

The Affordable Care Act’s health insurance marketplaces open for enrollment today for the sixth time. But this year the marketplace health plans in many states will face some new competition from insurance products that don’t meet the law’s standards, including the ban on denying coverage or charging more based on a person’s preexisting health conditions.

New Trump administration regulations released earlier this year have undermined the coverage protections in the ACA by making it possible for insurers to renew often skimpy short-term health insurance for up to three years, and for small businesses to form associations that sell substandard health plans. One of the reasons insurers can charge low premiums for these plans is that they generally cover less that ACA-compliant plans and insurers can deny them to people with diabetes or a history of cancer, for example. Only healthy people get these plans. And the more healthy people who buy them, the more expensive coverage becomes for people with a history of illness who buy their own insurance and have incomes too high to qualify for marketplace subsidies. In guidance released last week, the administration will allow states to further encourage the sale of these plans by letting people use federal subsidies to buy them.

As a nation, it is important for us to focus our energy on ways to improve people’s health. We are experiencing an unprecedented decline in life expectancy which will ultimately affect our economic health and the ability of Americans to compete in a global workforce. One of the most basic things we can do is preserve the coverage protections for people with health problems that have been law for more than four years, rather than poke holes in them. Americans say they support this idea. Recent polls have found that majorities of Americans believe that people with health conditions should not be denied affordable health insurance and health care. As a result, House and Senate candidates of both parties are running on their support for protecting coverage for people with preexisting conditions. But some of those very candidates voted to repeal the ACA last year.

The ACA has dramatically improved the ability of people with preexisting conditions to buy coverage. In 2010, before the law passed, we conducted a survey that found 70 percent of people with health problems said it was very difficult or impossible to buy affordable coverage, and just 36 percent said they ended up purchasing a health plan. By 2016, the percentage of people who had trouble buying an affordable plan had dropped down to 42 percent — still high but much improved — and 60 percent ultimately bought a plan.

While the congressional ACA repeal bills failed last year, a Republican Congress could try again next year. And in the meantime, the law’s preexisting conditions protections and other provisions face another threat from a lawsuit brought by Republican governors and attorneys general in 20 states. The U.S Department of Justice has agreed with the plaintiff states in part, and refused to defend the law’s preexisting condition protections. The court decision is pending. Should the states win, an estimated 17 million people could become uninsured.

Some congressional candidates from these states and others are pointing to their support for Republican proposals, such as the “Ensuring Coverage for Patients with Pre-Existing Conditions Act,” as proof they support coverage for preexisting conditions. This bill would prevent insurers from refusing or varying premiums based on preexisting conditions. But, unlike the ACA, this bill would allow insurers to sell plans that entirely exclude coverage for care pertaining to the preexisting conditions themselves. The reality is that this bill would not protect sick Americans, or those who may become ill in the future, from high out-of-pocket health care costs.

Several million people will be going to the marketplaces in the next few weeks to sign up for coverage since they do not have it through an employer. At this time, not one of them who buys a plan in the marketplace has to fear that an insurance company will deny them coverage or charge them a higher premium because of their health. The efforts to undermine the individual market and invalidate the ACA’s consumer protections are real-life threats for people who depend on this insurance for their health care. The nation cannot move forward with tackling our most pressing health care problems if we continue to debate a core protection of the ACA that most Americans support.